The Health Insurance Rate Review Grant Program

Transcription

1 U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services Center for Consumer Information and Insurance Oversight The Health Insurance Rate Review Grant Program Grants to Support States in Health Insurance Rate Review-Cycle II Initial Announcement Invitation to Apply for 2011 Funding Opportunity Number: PR-PRP CFDA: Cycle II Applicable Dates: Date: February 24, 2011 Voluntary Letter of Intent to Apply: July 1, 2011 Phase I: Application Due Date: August 15, 2011 Phase II: Application Due Dates: August 15, 2012; August 15, 2013 Anticipated Notice of Grant Award Phase I: Prior to September 30, 2011 Anticipated Notice of Grant Award Phase II: Prior to September 30, 2012 Prior to September 30, 2013 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete the application associated with this information collection is estimated to average 475 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C , Baltimore, Maryland

2 Table of Contents Page I. Funding Opportunity Description 1. Funding Description Overview Authority Program Requirements...8 II. III. IV. Award Information 1. Total Funding Award Amount Anticipated Award Date The Period of Performance Milestones and Funding Number of Awards Type of Award...12 Eligibility Information 1. Eligible Applicants Commitment to Effective Rate Review Eligibility for Additional Funds Continued Eligibility Central Contracting Registration (CCR) Requirement Cost Sharing/Matching Maintenance of Effort One Application Requirement, with exception Pre-Application Conference Call...14 Application and Submission Information 1. Address to Request Application Package Format, Standard Form (SF) and Content Requirements Submission Dates and Times Intergovernmental Review Funding Restrictions...27 V. Application Review and Selection Information 1. Criteria Review and Selection Process

3 VI. VII. Award Administration Information 1. Award Notices Administrative and National Policy Requirements Terms and Conditions Reporting...31 Agency Contacts 1. Programmatic Contact Grants Management Contact...34 VIII. Other Information 1. Attachment A- Prohibited Uses of Grant Funds 2. Attachment B- Definitions 3. Attachment C- Application Check Off List 4. Attachment D-Guidance for Preparing a Budget Request and Narrative in Response to SF 424A 5. Attachment E: Required Reporting Information for Consultant Hiring 6. Attachment F: Federal Procurement Requirement for Grantees 7. Attachment G: Workload and Performance Funds Allocation and Example 3

4 I. FUNDING OPPORTUNITY DESCRIPTION 1. Funding Description Overview a. Statutory Provisions On March 23, 2010, the President signed into law the Patient Protection and Affordable Care Act. On March 30 th, 2010, the Health Care and Education Reconciliation Act of 2010 was also signed into law. The two laws are collectively referred to as the Affordable Care Act. The Affordable Care Act includes a wide variety of provisions designed to promote accountability, affordability, quality, and accessibility in the health care system. The Affordable Care Act also includes significant grant funding for States to work with the Federal government to implement health reform. Section 1003 of the Affordable Care Act adds a new section 2794 to the Public Health Service (PHS) Act entitled, Ensuring That Consumers Get Value for Their Dollars. Specifically, Section 2794 requires the Secretary of Health and Human Services (HHS), in conjunction with the States, to establish a process for the annual review of health insurance premiums 1 to protect consumers from unreasonable rate increases. The statute specifies that the process established by the Secretary shall require health insurance issuers to submit to the Secretary and the relevant State a justification for unreasonable premium increases prior to the implementation of the increase, and that such issuers shall prominently post such information on their Internet websites. The Secretary shall ensure public disclosure of information on such increases and justifications for all health insurance issuers. In addition, Section 2794 directs the Secretary to carry out a program to award grants to States to help them develop, or improve and enhance their current health insurance rate review and reporting processes. 2 Congress has appropriated $250 million for this grant program for the federal fiscal years (FFYs) Preliminary results indicate that effective rate review is helping States to slow down premium growth. In Connecticut, for instance, the State Insurance Commissioner rejected a proposed 19.9 percent premium increase by the State s largest insurer that would have raised costs for 48,000 consumers. Heightened scrutiny of rate increases in California has led to increased review of a proposed 59 percent increase in one company s rates. 1 The Affordable Care Act uses the term premium ; however, the National Association of Insurance Commissioners uses the term, rate for purposes of industry review. To remain aligned with industry terminology, 2 For the Rate Review Grants established under Section 2794 of the PHS Act, the United States Territories of American Samoa, Guam, Northern Mariana Islands, Puerto Rico and the Virgin Islands are included in the definition of State. 4

5 Finally, in Massachusetts, insurance authorities over the past year rejected 235 of 274 rate filings that the division found to be "unreasonable or excessive," with some carriers applying for base rate increases of up to 34 percent. As a result, rate increases submitted by the state s nine major carriers and approved by the Division of Insurance range from a weighted average increase of 1.4 percent to 9.9 percent for the quarter starting April 1, 2011 when more than 250,000 Massachusetts residents will renew their health plans. b. Cycle I Rate Review Grants The Cycle I Funding Opportunity Announcement (FOA) was released on June 7, 2010, with the first grant awards made to States on August 9, During Cycle I, forty-five States and the District of Columbia applied for grants, and each was awarded $1 million in grant funds. The grant recipients proposed to use Cycle I grant funding in a number of ways including seeking additional legislative authority to review health insurance rate increases, expanding the scope of rate review, improving the rate review process, and making information on health insurance rates more publicly available through transparency initiatives and by developing and upgrading technology. Many states are already making progress toward enhancing their rate review processes as a result of receiving Cycle I funds. For instance, Montana currently lacks the authority to collect rate filings. As part of the current Cycle 1 grant program, they are seeking legislation to give them the necessary authority to collect such filings. Arkansas plans to increase their rate review authority by seeking legislation that would allow them to implement an enhanced rate review process, while simultaneously hiring a new team to improve rate review within their current authority. Finally, New Jersey has made significant strides in staffing their rate review team through the use of grant funds. The period of performance for Cycle I of the Rate Review Grant Program for the forty-five States and the District of Columbia ends on September 30, A second Cycle I FOA was released on September 1, 2010 to enable the U.S. Territories to apply. The award announcement from this FOA is still pending. c. Proposed Rule On December 23, 2010, HHS published a Notice of Proposed Rulemaking (NPRM) describing how it proposed to implement the rate review process described in Section 2794 of the (PHS) Act. 3 The regulation proposed that any rate increase of 10 percent or more would be subject to review. The proposed regulation sets forth a proposal that insurers report certain health insurance rate information to both the Secretary and the States in which they operate, including: 3 See Rate Increase Disclosure and Review, 75 Fed. Reg (December 23, 2010) 5

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7 the receipt of the Notice of Grant Award. Further, a State will have to demonstrate in its quarterly reports that it is meeting the milestones in its application that support the development or enhancement of an effective rate review program. For States that, as of the Cycle II, Phase I application due date, cannot demonstrate that they would satisfy the requirements outlined in the preceding paragraph, this FOA provides the opportunity to apply for Cycle II, Phase II grants. In order to be eligible for and receive Cycle II, Phase II funding, a State must demonstrate that, as of the Cycle II, Phase II application due date, it either: (i) already meets the effective rate review criteria described in the final regulation; or (ii) as a result of receiving Cycle II, Phase II grant funds, will have the resources to meet those criteria within the twelve month period following the receipt of the Notice of Grant Award. As is the case for State s receiving Cycle II, Phase I grants, a State receiving Phase II grant funds will have to demonstrate in its quarterly reports that it is meeting the milestones in its application that support the development or enhancement of an effective rate review program. The Cycle II Rate Review Grant FOA may be updated and/or adjusted based on the final rate review regulation. e. Cycle II: Additional Rate Review Grant Funds In addition to the Baseline Grant Award, two additional segments of funds are also available under the Cycle II, Phase I and Phase II grants. Workload funds are available to States based on population and the number of health insurance issuers in the state. While the proposed rate review regulation would not require that States have the authority or ability to disapprove rates in order to be considered a State with an effective rate review program, the Performance funds are available to those States that have the authority to disapprove unreasonable rate increases. States with such authority may also have larger workloads and therefore have higher resource needs. Certain States will be eligible, and awarded both the Workload and the Performance funds. The Workload and Performance funds can be for a period of one, two, or three years, as stipulated in the Notice of Grant Award. States receiving the Workload or Performance funds will be required to use these funds in support of enhancing or developing an effective rate review program as discussed in Section I, Part 3 (Program Requirements). More information on the methodology for determining the Workload and the Performance fund eligibility and amount is provided in Section II (Award Information), Part 2 (Award Amount) and Attachment G ( Workload and Performance Awards Allocation and Example). Additional details on the Cycle II Phase I and Phase II eligibility criteria, application criteria, and grant programmatic requirements are outlined in Sections III (Eligibility Information), Section IV (Application and Submission Information) and Section V (Application Review and Selection Information). 7

8 2. Authority This grant program is being administered by HHS under the authority of section 2794 of the Public Health Service Act entitled, Ensuring That Consumers Get Value for Their Dollars. 3. Program Requirements a. Eligibility The complete eligibility criteria for the Cycle II Rate Review Grant Program are outlined in Section III (Eligibility Information). b. Effective Rate Review Program In order to be eligible for an award under Cycle II, for either Phase I or II awards, a State must be able to demonstrate at the time of the application either that it already meets the criteria for an effective rate review program, or that with the funding resources from the grant it can achieve an effective rate review program. An effective rate review program meets the following criteria: 1. The State receives data and documentation sufficient to determine whether a rate increase is unreasonable; 2. The State has adequate resources to effectively review that data and documentation in a timely manner; 3. The State s review examines the reasonableness of the assumptions used by the issuer in developing its rate proposal and the validity of the historical data underlying those assumptions, in accordance with specific areas of analysis set forth in the regulation; and 4. The State s determination of whether a rate increase is unreasonable is based on a standard set forth in State statute or regulation. States that do not qualify as an effective review State at the time of application must use grant funds to achieve this status by meeting the criteria outlined above within the first year of their Cycle II grant award. c. Establish or Enhance Rate Review Activities States will be required to use grant funds to develop or enhance their current capacity to review and, to the extent permitted by State law, approve or deny rate increases in the individual and group markets through an effective rate review program. For example, a State may use a Cycle II grant award as a basis for seeking additional legislative authority to review rate increases, to hire additional actuaries to conduct thorough reviews of rate increases, or to invest in information technology (IT) systems that allow for the public disclosure of rate 8

9 information and trends. Each State must include in its grant Project Narrative and Rate Review Work Plan a proposal for program activities that enhance its current effective rate review program or must demonstrate how it would lead to the development of an effective rate review program. d. Reporting to the Secretary on Rate Increase Patterns States will be required to submit certain rate filing data to HHS as a condition of participating in the Cycle II Rate Review Grant Program. See Section IV, Application and Submission Information, for additional information. e. Rate Review Work Plan Each State applying for Cycle II funding will be required to develop and submit a Rate Review Work Plan that outlines specific milestones for successful development and enhancement of its rate review program. For example, a State seeking to establish an effective rate review program by using grant funds to hire actuaries should include as a milestone the anticipated number of new actuaries on staff or under contract at the end of the first grant year. These milestones must be articulated clearly, be measureable, and be appropriate for the award time period. Section IV (Application and Submission Information) provides additional information and examples of rate review enhancement milestones. A State applying for a Cycle II, Phase I award will need to provide a Rate Review Work Plan with milestones from date of award in FFY 2011 through FFY A State applying in Cycle II, Phase II must provide a Rate Review Work Plan with milestones from date of award in FFY 2012 or FFY 2013 through FFY f. Demonstrating Progress toward Milestones Progress toward the milestones outlined in the Rate Review Work Plan will be reported during the quarterly programmatic progress reports and in the required programmatic annual reports. States will have the opportunity to update and amend their Rate Review Work Plans on a quarterly basis throughout the Cycle II grant program. However, a State cannot alter its Work Plan to defer the objective of establishing an effective rate review program within the first year of receiving the grant. HHS will work closely with a State in the event that a State updates its Work Plan as the Rate Review Grant Program further evolves, and HHS will make technical assistance available to facilitate and support State progress throughout the grant program. State progress will be evaluated based on the submission of quarterly progress reports and progress toward the described rate review enhancement milestones. Additional technical assistance will be available to States that are not showing progress toward the required milestones; however, HHS may restrict future grant funds for certain grant activities if milestones are not met. More detailed information will be provided on the quarterly and annual reports and the reporting structure in the Notice of Grant award. 9

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14 The Grants Management Specialist assigned to monitor the sub award reports and Executive Compensation is Iris Grady ). 6. Cost Sharing/Matching Awardees are not required to provide matching contributions. 7. Maintenance of Effort: The State share of funds expended for rate review activities under the State s proposed plan for rate review shall not be less than the State (non-grant) funds expended for rate review activities in the fiscal year preceding the fiscal year for which the grant is awarded. All applicants must provide assurances that grant funds will only be used to enhance the State s existing rate review efforts, and not as a substitute for existing funding for such efforts. Applicants are allowed to use Cycle II funding to continue Cycle I activities. 8. One Application Requirement, with exception: With one exception, only one application may be submitted by a single eligible State for funding in Cycle II. In a State in which there are two regulating entities, each with a primary responsibility over the regulation of a portion of the private health insurance market, two applications from the State will be permitted. A State with two applications will be required to split the total grant award allocated for that State and therefore must collaborate with the other applicable entity regarding a proposed budget. However, each State entity will be viewed as a distinct grantee responsible for submitting separate programmatic and financial reports. 9. Pre-Application Conference Call: HHS will hold pre-application conference calls for potential applicants. On the conference call HHS staff will provide an overview of this grant program, will offer budget guidance, will review the guidance provided by this FOA and other available materials, and will include an opportunity for States to ask questions. Details on the date, time and call-in information will be provided prior to the conference call. IV. APPLICATION AND SUBMISSION INFORMATION 1. Address to Request Application Package: This Funding Opportunity Announcement contains all the instructions to enable a potential applicant to apply. The application should be written primarily as a narrative with the addition of standard forms required by the Federal government for all grants. It is recommended that a Letter of Intent be submitted by 4:00 pm Eastern Standard Time on July 1, The Letter of Intent should include a brief explanation of a State s intent to apply for the Cycle II Grant Program. The purpose of the Letter of Intent is to estimate the number of 14

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18 Note: On SF 424 Application for Federal Assistance: Item 15 Descriptive Title of Applicant s Project. Please indicate in this section the name of this grant: Grants to Support States in Health Insurance Rate Review-Cycle II Check box C to item 19, as Review by State Executive Order does not apply to these grants. Assure that the total Federal grant funding requested is for the entire period of the grant. B. Required Letters of Support Each applicant must submit a letter from the Governor (or the Mayor, if from the District of Columbia) officially endorsing the grant application and the proposed program plan. C. Applicant s Application Cover Letter or Cover Page A letter from the applicant must identify the: Project Title Applicant Name Project Director Name (with and phone number) D. Project Abstract A one-page abstract should serve as a succinct description of the proposed project and must include the goals of the project, the total budget, and a description of how the grant will be used to enhance health insurance rate review in the State. Place the following at the top of the abstract for the application: Application title Applicant organization name Program applying under, including funding opportunity number Project Director Project Director Address Project Director contact phone numbers (phone and fax) Project Director address Organizational Website address, if applicable Projected date(s) for project(s) completion 18

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29 date. If an applicant does not submit all of the required documents and does not address each of the topics described below, the applicant risks not being award a Cycle II grant. As indicated in Section IV, Application and Submission Information, all applicants must submit the following: 1. Standard Forms 2. Required Governor Letter of Support 3. Applicant s Cover Letter 4. Project Abstract 5. Project Narrative 6. Rate Review Work Plan 7. Budget Narrative 8. Required Supporting Documentation 2. Review and Selection Process A team consisting of qualified experts will review all applications. The review process will include the following: 1. Applications will be screened to determine eligibility for further review using the criteria detailed in Section III, Eligibility Information of this Funding Opportunity Announcement. Applications that are received late or fail to meet the eligibility requirements as detailed in this Funding Opportunity Announcement or do not include the required forms will not be reviewed. 2. Procedures for assessing the technical merit of grant applications have been instituted to provide for an objective review of applications and to assist the applicant in understanding the standards against which each application will be judged. The Review criteria described in Section V (Application Review and Selection Information) will be used to review applications. Applications will be evaluated by an objective review committee. Applicants should pay strict attention to addressing all these grant criteria, as they are the basis upon which the reviewers will evaluate their applications. 3. Final award decisions will be made by an HHS program official. In making these decisions, the HHS program official will take into consideration the following: recommendations of the review panel; reviews for programmatic and grants management compliance; the reasonableness of the estimated cost to the government and anticipated results; and the likelihood that the proposed project will result in the benefits expected. HHS reserves the right to conduct pre-award Budget Negotiations with potential awardees. 29

30 VI. Award Administration Information 1. Award Notices Successful applicants will receive a Notice of Grant Award signed and dated by an HHS Grants Management Officer. The Notice of Grant Award is the document authorizing the grant award and it will be sent through electronic mail to the State as listed on the SF 424. Any communication between HHS and applicants prior to issuance of the Notice of Grant Award is not an authorization to begin performance of a project. Unsuccessful applicants are notified within 30 days of the final funding decision and will receive a disapproval letter via U.S. Postal Service or electronic mail. Federal Funding Accountability and Transparency (FFATA) sub award Reporting Requirement: Awards issued under this FOA are subject to the reporting requirements of the Federal Funding Accountability and Transparency Act of 2006 (Pub. L ), as amended by section 6202 of Public Law and implemented by 2 CFR Part 170. Grant recipients must report information for each sub award of $25,000 or more in Federal funds and executive total compensation for the recipient s and sub recipient s five most highly compensated executives as outlined in Appendix A to 2 CFR Part 170. Information about the Federal Funding and Transparency Act Sub award Reporting System (FSRS) is available at 2. Administrative and National Policy Requirements The following standard requirements apply to applications and awards under this FOA: A. Specific administrative requirements, as outlined in 2 CFR Part 215 and 45 CFR Part 92, apply to grants awarded under this announcement. B. All States receiving awards under this grant project must comply with all applicable Federal statutes relating to nondiscrimination including, but not limited to: i. Title VI of the Civil Rights Act of 1964, ii. Section 504 of the Rehabilitation Act of 1973, iii. The Age Discrimination Act of 1975, iv. Hill-Burton Community Service nondiscrimination provisions, and v. Title II Subtitle A of the Americans with Disabilities Act of C. All equipment, staff, other budgeted resources, and expenses must be used exclusively for the project identified in the applicant s grant application or agreed upon subsequently with HHS, and may not be used for any prohibited uses. 30

31 3. Terms and Conditions Grants issued under this FOA are subject to the Health and Human Services Grants Policy Statement (HHS GPS) at Standard terms and special terms of award will accompany the Notice of Grant Award. Potential applicants should be aware that special requirements could apply to grant awards based on the particular circumstances of the effort to be supported and/or deficiencies identified in the application by the HHS review panel. The general terms and conditions that are outlined in section II of the HHS GPS will apply as indicated unless there are statutory, regulatory, or award-specific requirements to the contrary (as specified in the Notice of Grant Award). Sub award Reporting and Executive Compensation: Awards issued under this FOA are subject to the reporting requirements of the Federal Funding Accountability and Transparency Act of 2006 (Pub. L ), as amended by section 6202 of Public Law , and implemented by 2 CFR Part 170. Grant recipients must report information for each sub award of $25,000 or more in Federal funds and total executive compensation for the recipient s and sub recipient s five most highly compensated executives as outlined in Appendix A to 2 CFR Part 170. Information about the Federal Funding and Transparency Act Sub award Reporting System (FSRS) is available at All prime grantees will be required to provide a DUNS number in order to be able to register in FSRS as a prime grantee user. If your organization does not have a DUNS number, you will need to obtain one from Dun & Bradstreet. Call D&B at if you do not have a DUNS number. Once you have obtained a DUNS Number from D&B, you must then register with the Central Contracting Registration (CCR) at Organizations must report executive compensation as part of the registration profile at by the end of the month following the month in which this award is made, and annually thereafter. After you have completed your CCR registration, you will be able to register in FSRS as a prime grantee user. Intellectual Property As a term and condition of a grant award, under 45 CFR 92.34, the Federal awarding agency will retain a royalty-free, nonexclusive, irrevocable license to reproduce, publish or otherwise use and authorize others to use, for Federal government purposes, the copyright in any work developed under the grant, or a sub grant or subcontract, and in any rights to a copyright purchased with grant support. 4. Reporting All successful applicants under this announcement must comply with the following reporting and review activities: 31

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33 Grantees must report on a quarterly basis cash transaction data via the Payment Management System (PMS) using the FFR. The FFR, containing cash transaction data, is due within 30 days after the end of each quarter. The quarterly reporting due dates are as follows: 4/30, 7/30, 10/30, 1/30. A Quick Reference Guide for completing the FFR in PMS is at: Within 90 calendar days of the project period end date, Grantees must also report on the FFR their expenditures and any program income generated in lieu of completing a Financial Status Report (FSR) (SF269/269A). Expenditures and any program income generated should only be included on the final, hard copy FFR. G. Transparency Act Reporting Requirements New awards issued under this funding opportunity announcement are subject to the reporting requirements of the Federal Funding Accountability and Transparency Act of 2006 (Pub. L ), as amended by section 6202 of Public Law and implemented by 2 CFR Part 170. Grant and cooperative agreement recipients must report information for each first-tier sub award of $25,000 or more in Federal funds and executive total compensation for the recipient s and sub recipient s five most highly compensated executives as outlined in Appendix A to 2 CFR Part 170 (available online at Competing Continuation awardees may be subject to this requirement and will be so notified in the Notice of Award. H. Audit Requirements Grantees must comply with audit requirements of the Office of Management and Budget (OMB) Circular A-133. Information on the scope, frequency, and other aspects of the audits can be found on the Internet at I. Payment Management Requirements Grantees must submit a quarterly electronic SF 425 via the Payment Management System. The report identifies cash expenditures against the authorized funds for the grant. Failure to submit the report may result in the inability to access grant funds. The SF 425 Certification page should be faxed to the PMS contact at the fax number listed on the SF 425, or it may be submitted to the: Division of Payment Management HHS/ASAM/PSC/FMS/DPM PO Box 6021 Rockville, MD Telephone: (877)

34 VII. AGENCY CONTACTS Programmatic Contact Programmatic questions about the Grants to States for Health Insurance Rate Review can be directed to: Jacqueline Roche The Center for Consumer Information and Insurance Oversight Centers for Medicare and Medicaid Services (301) Grants Management Official/Business Administration Michelle Feagins Office of Acquisition and Grants Management Centers for Medicare and Medicaid Services (301) List of Attachments A. Prohibited Uses of Grant Funds B. Definitions C. Application Check List D. Guidance for Preparing a Budget Request and Narrative in Response to SF 424 A E. Required Reporting Information for Consultant Hiring F. Federal Procurement Requirement for Grantees G. Workload and Performance Funds Allocation and Example 34

35 ATTACHMENT A Prohibited Uses of Grant Funds The Department of Health and Human Services Grants for Rate Review Cycle II for FY funds may not be used for any of the following: 1. To cover the costs to provide direct services to individuals. 2. To match any other Federal funds. 3. To provide services, equipment, or supports that are the legal responsibility of another party under Federal or State law (e.g.; vocational rehabilitation or education services) or under any civil rights laws. Such legal responsibilities include, but are not limited to, modifications of a workplace or other reasonable accommodations that are a specific obligation of the employer or other party. 4. To supplant existing State, local, or private funding of infrastructure or services such as staff salaries, etc. 35

36 ATTACHMENT B Definitions Actuarial justification The demonstration by an insurer, as certified by an actuary that the rates collected are justified, relative to the benefits provided under the plan and/or that the allocation of premiums among policyholders is proportional to the distribution of their expected benefits, subject to limitations of state and federal law. Adjusted community rating A method of pricing insurance where rates are not based upon a policyholder's health status, but may be based upon other factors, such as age and geographic location. Affordable Care Act Public Law (March 23, 2010) Calendar Year A twelve-month period beginning on the first day of January and ending on the last day of the following December. Community rating A method of pricing insurance, where each policyholder pays the same rate, regardless of health status, age or other factors. Conflicts of Interest A circumstance where the private or financial interests of an individual or entity conflict or appear to conflict with official or fiduciary responsibilities. Group health insurance coverage offered in connection with a group health plan. Group health plan An employee welfare benefit plan (as defined in section 3(I) of ERISA [29 U.S.C (1)] to the extent that the plan provides medical care to employees or their dependents directly or through insurance, reimbursement or otherwise. Guaranteed issue Guaranteed issue is a requirement that a health insurance issuer must allow enrollment regardless of health, age, gender or other factors, such as pre-existing condition, that might predict use of health services. Guaranteed renewability A requirement that health insurance issuers renew coverage under a health insurance policy at the option of the policyholder, except in certain limited circumstances, such as failure to pay premiums, fraud, termination of the plan, and relocation of an individual to outside the plan service area. Federal fiscal year A twelve-month period beginning on the first day of October and ending on the last day of the following September. File and Use A State requirement that a health insurance issuer file a proposed rate increase with the insurance commissioner before implementation, but need not first obtain the commissioner s affirmative approval. The commissioner may or may not have the authority to disapprove the rate after it takes effect. 36

37 Health insurance coverage For purposes of Federal law, as defined in 45 C.F.R , benefits providing payment for medical services under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by a health insurance issuer. Health insurance issuer An insurance company, insurance services, or insurance organization (including a health maintenance organization that is licensed to engage in the business of insurance in a State and which is subject to State law insurance regulations and statutes. HIPAA (Health Insurance Portability and Accountability Act of 1996) Public Law No , 110 Stat (1996). Individual market The market segment for health insurance coverage sold directly to individuals rather than in connection with a group health plan. Informational filing A rate filing pursuant to State or regulation that allows a health insurer to increase its rates at will as long as the insurer files the rate increase contemporaneously with or soon after the effective date of the increase, whether or not the State Insurance Commissioner has the authority to disapprove the rate after it takes effect. Lead Agency Designated state agency authorized to supervise administration of the grant. Loss Ratio relationship of incurred losses plus loss adjustment expense to premiums received. Medical loss ratio For the purposes of the Affordable Care Act, the percentage of health insurance premiums that are spent by the insurance company on health care clinical services and activities that improve health care quality in relation to premiums received. No file A State statutory or regulatory provision pursuant to which an insurer is not required to file rates with the State Insurance Commissioner. Preferred Provider Organization (PPO) A type of health insurance that provides health care coverage through a network of providers. Typically, the PPO requires the enrollee to pay increased cost sharing for services from an out-of-network provider. Premium The periodic payment by a consumer required to keep a policy in force. Prior approval A State statutory or regulatory requirement that an insurance company obtain the affirmative approval of the insurance commissioner before implementing any rate increase Prospective premium rating authority State statutory or regulatory authority requiring prior approval of rates associated with health insurance policies. Retrospective rating authority The authority under state law to review and approve or disapprove rates based on actual loss experience. Rate Review A State or Federal review of proposed health insurance rates and rate increases. 37

38 Self-insured A health plan is self-insured (or self-funded), when the entity that sponsors the plan (generally an entity) engaged in a business, trade, or profession, or a non-profit organization, such as a social, fraternal, labor, educational, religious, or professional organization), carries its own risk for the cost of medical claims instead of contracting with a health insurance issuer to assume the risk. Small group market The market segment for health insurance coverage offered to small employers as defined by relevant State or Federal Law. Solvency The ability of a health insurer to meet all of its financial obligations. Use and file A State statute or regulation that allows an insurer to increase its rates at will. Under this scheme although the insurer must file its rates with the State Insurance commissioner, the commissioner has no authority to disapprove the rate. 38

39 ATTACHMENT C: Application Check-Off List REQUIRED CONTENTS A complete application consists of the following materials. Please ensure that the project narrative is page-numbered. Forms/Mandatory Documents (Grants.gov) (with an original signature) SF 424: Application for Federal Assistance SF-424A: Budget Information SF-424B: Assurances-Non-Construction Programs SF-LLL: Disclosure of Lobbying Activities Project Site Location Form(s) Lobbying Certification Form (HHS checklist, 5161) Required Letters of Support (Governor) Applicant s Application Cover Letter Project Abstract Project Narrative Rate Review Work Plan Budget Narrative Required Supporting Documentation State Certification of Maintenance of Effort Descriptions for Key Personnel & Organizational Chart 39

40 ATTACHMENT D: Guidance for Preparing a Budget Request and Narrative in Response to SF424A INTRODUCTION This guidance is offered for the preparation of a budget request. Following this guidance will facilitate the review and approval of a requested budget by insuring that the required or needed information is provided. This is to be for done for each 12 month period of the grant project period. Applicants should be careful to only request funding for activities that will be funded by the Rate Review Grant. In the budget request, States should distinguish between activities that will be funded under this Cooperative Agreement and activities funded with other sources. Other funding sources include: IT Innovator Cooperative Agreements, Exchange Planning grants, other HHS grant programs, and other funding sources as applicable. A. Salaries and Wages For each requested position, provide the following information: name of staff member occupying the position, if available; annual salary; percentage of time budgeted for this program; total months of salary budgeted; and total salary requested. Also, provide a justification and describe the scope of responsibility for each position, relating it to the accomplishment of program objectives. Sample budget Personnel Total $ Rate Review Grant $ Funding other than Rate Review Grant $ Sources of Funding Position Title and Name Annual Time Months Amount Requested Project Coordinator $45, % 12 months $45,000 Susan Taylor Finance Administrator $28,500 50% 12 months $14,250 40

41 John Johnson Outreach Supervisor $27, % 12 months $27,000 (Vacant*) Sample Justification The format may vary, but the description of responsibilities should be directly related to specific program objectives. Job Description: Program Director - (Name and contact information) This position directs the overall operation of the project; responsible for overseeing the implementation of project activities, coordination with other agencies, development of materials, provisions of in service and training, conducting meetings; designs and directs the gathering, tabulating and interpreting of required data, responsible for overall program evaluation and for staff performance evaluation; and is the responsible authority for ensuring necessary reports/documentation are submitted to HHS. This position relates to all program objectives. B. Fringe Benefits Fringe benefits are usually applicable to direct salaries and wages. Provide information on the rate of fringe benefits used and the basis for their calculation. If a fringe benefit rate is not used, itemize how the fringe benefit amount is computed. Sample Budget Fringe Benefits Total $ Rate Review Grant $ Funding other than Rate Review Grant $ 41

42 Sources of Funding 25% of Total salaries = Fringe Benefits If fringe benefits are not computed by using a percentage of salaries, itemize how the amount is determined. Example: Project Coordinator Salary $45,000 Retirement 5% of $45,000 = $2,250 FICA 7.65% of $45,000 = 3,443 Insurance = 2,000 Workers Compensation = C. Consultant Costs Total: This category is appropriate when hiring an individual to give professional advice or services (e.g., training, expert consultant, etc.) for a fee but not as an employee of the grantee organization. Hiring a consultant requires submission of the following information to HHS (see Required Reporting Information for Consultant Hiring later in this Appendix): 1. Name of Consultant; 2. Organizational Affiliation (if applicable); 3. Nature of Services to be Rendered; 4. Relevance of Service to the Project; 5. The Number of Days of Consultation (basis for fee); and 6. The Expected Rate of Compensation (travel, per diem, other related expenses) list a subtotal for each consultant in this category. 42

43 If the above information is unknown for any consultant at the time the application is submitted, the information may be submitted at a later date as a revision to the budget. In the body of the budget request, a summary should be provided of the proposed consultants and amounts for each. D. Equipment Provide justification for the use of each item and relate it to specific program objectives. Maintenance or rental fees for equipment should be shown in the Other category All IT equipment should be uniquely identified. As an example, we should not see a single line item for software. Show the unit cost of each item, number needed, and total amount. Sample Budget Equipment Total $ Rate Review Grant $ Funding other than Rate Review Grant $ Sources of Funding Item Requested How Many Unit Cost Amount Computer Workstation 2 ea. $2,500 $5,000 Fax Machine 1 ea Sample Justification Total $5,600 Provide complete justification for all requested equipment, including a description of how it will be used in the program. For equipment and tools which are shared among programs, please cost allocate as appropriate. States should provide a list of hardware, software and IT equipment which will be required to complete this effort. Additionally, they should provide a list of non-it equipment which will be required to complete this effort. 43

44 E. Supplies Individually list each item requested. Show the unit cost of each item, number needed, and total amount. Provide justification for each item and relate it to specific program objectives. If appropriate, General Office Supplies may be shown by an estimated amount per month times the number of months in the budget category. Sample Budget Supplies Total $ Rate Review Grant $ Funding other than Rate Review Grant $ Sources of Funding General office supplies (pens, pencils, paper, etc.) 12 months x $240/year x 10 staff = $2,400 Educational Pamphlets (3,000 $1 each) = $3,000 Educational Videos (10 $150 each) = $1,500 Word Processing Software (@ $400 specify type) = $ 400 Sample Justification General office supplies will be used by staff members to carry out daily activities of the program. The education pamphlets and videos will be purchased from XXX and used to illustrate and promote safe and healthy activities. Word Processing Software will be used to document program activities, process progress reports, etc. 44

45 F. Travel Dollars requested in the travel category should be for staff travel only. Travel for consultants should be shown in the consultant category. Travel for other participants, advisory committees, review panel, etc. should be itemized in the same way specified below and placed in the Other category. In-State Travel Provide a narrative justification describing the travel staff members will perform. List where travel will be undertaken, number of trips planned, who will be making the trip, and approximate dates. If mileage is to be paid, provide the number of miles and the cost per mile. If travel is by air, provide the estimated cost of airfare. If per diem/lodging is to be paid, indicate the number of days and amount of daily per diem as well as the number of nights and estimated cost of lodging. Include the cost of ground transportation when applicable. Out-of-State Travel Provide a narrative justification describing the same information requested above. Include HHS meetings, conferences, and workshops, if required by HHS. Itemize out-of-state travel in the format described above. Sample Budget Travel (in-state and out-of-state) Total $ Rate Review Grant $ Rate Review Grant $ Sources of Funding In-State Travel: 1 trip x 2 people x 500 miles r/t x.27/mile = $ days per diem x $37/day x 2 people = nights lodging x $67/night x 2 people = trips x 1 person x 300 miles avg. x.27/mile = 2,025 45

46 Total $ 2,577 Sample Justification The Program Director and the Outreach Supervisor will travel to (location) to attend an eligibility conference. The Project Coordinator will make an estimated 25 trips to local outreach sites to monitor program implementation. Sample Budget Out-of-State Travel: 1 trip x 1 person x $500 r/t airfare = $500 3 days per diem x $45/day x 1 person = night s lodging x $88/night x 1 person = 88 Ground transportation 1 person = 50 Total $773 Sample Justification The Project Coordinator will travel to HHS, in Atlanta, GA, to attend the HHS Conference. G. Other This category contains items not included in the previous budget categories. Individually list each item requested and provide appropriate justification related to the program objectives. 46

47 Sample Budget Other Total $ Rate Review Grant $ Funding other than the Rate Review Grant $ Sources of Funding Telephone ($ per month x months x #staff) = $ Subtotal Postage ($ per month x months x #staff) = $ Subtotal Printing ($ per x documents) = $ Subtotal Equipment Rental (describe) ($ per month x months) = $ Subtotal Internet Provider Service ($ per month x months) = $ Subtotal Sample Justification Some items are self-explanatory (telephone, postage, rent) unless the unit rate or total amount requested is excessive. If not, include additional justification. For printing costs, identify the types and number of copies of documents to be printed (e.g., procedure manuals, annual reports, materials for media campaign). 47

48 H. Contractual Costs Cooperative Agreement recipients must submit to HHS the required information establishing a third-party contract to perform program activities (see Required Information for Contract Approval later in this Appendix). 1. Name of Contractor; 2. Method of Selection; 3. Period of Performance; 4. Scope of Work; 5. Method of Accountability; and 6. Itemized Budget and Justification. If the above information is unknown for any contractor at the time the application is submitted, the information may be submitted at a later date as a revision to the budget. Copies of the actual contracts should not be sent to HHS, unless specifically requested. In the body of the budget request, a summary should be provided of the proposed contracts and amounts for each. I. Total Direct Costs $ Show total direct costs by listing totals of each category. J. Indirect Costs $ To claim indirect costs, the applicant organization must have a current approved indirect cost rate agreement established with the cognizant Federal agency. A copy of the most recent indirect cost rate agreement must be provided with the application. Sample Budget 48

49 The rate is % and is computed on the following direct cost base of $. Personnel $ Fringe $ Travel $ Supplies $ Other $ Total $ x % = Total Indirect Costs If the applicant organization does not have an approved indirect cost rate agreement, costs normally identified as indirect costs (overhead costs) can be budgeted and identified as direct costs. 49

50 ATTACHMENT E: REQUIRED REPORTING INFORMATION FOR CONSULTANT HIRING This category is appropriate when hiring an individual who gives professional advice or provides services for a fee and who is not an employee of the grantee organization. Submit the following required information for consultants: 1. Name of Consultant: Identify the name of the consultant and describe his or her qualifications. 2. Organizational Affiliation: Identify the organization affiliation of the consultant, if applicable. 3. Nature of Services to be Rendered: Describe in outcome terms the consultation to be provided including the specific tasks to be completed and specific deliverables. A copy of the actual consultant agreement should not be sent to HHS. 4. Relevance of Service to the Project: Describe how the consultant services relate to the accomplishment of specific program objectives. 5. Number of Days of Consultation: Specify the total number of days of consultation. 6. Expected Rate of Compensation: Specify the rate of compensation for the consultant (e.g., rate per hour, rate per day). Include a budget showing other costs such as travel, per diem, and supplies. 7. Method of Accountability: Describe how the progress and performance of the consultant will be monitored. Identify who is responsible for supervising the consultant agreement. REQUIRED INFORMATION FOR CONTRACT APPROVAL All contracts require reporting the following information to HHS. 1. Name of Contractor: Who is the contractor? Identify the name of the proposed contractor and indicate whether the contract is with an institution or organization. 2. Method of Selection: How was the contractor selected? State whether the contract is sole source or competitive bid. If an organization is the sole source for the contract, include an explanation as to why this institution is the only one able to perform contract services. 3. Period of Performance: How long is the contract period? Specify the beginning and ending dates of the contract. 50